ICU PROCEDURES: Enteral Feeding

by | Sep 13, 2024 | Nurse Article | 0 comments

ICU PROCEDURES: Enteral Feeding

ICU Procedures: Enteral Feeding – Nursing Management

Enteral feeding is the delivery of nutrients directly into the gastrointestinal (GI) tract via a tube. In ICU patients, enteral feeding is preferred when the GI tract is functioning, but oral intake is not possible due to critical illness, sedation, or mechanical ventilation. Effective nursing management ensures that enteral feeding is administered safely, preventing complications like aspiration, infection, or nutritional imbalances.

Types of Enteral Feeding Tubes:

  1. Nasogastric (NG) Tube: Inserted through the nose into the stomach.
  2. Orogastric (OG) Tube: Inserted through the mouth into the stomach.
  3. Nasointestinal Tube: Inserted through the nose into the small intestine (jejunum).
  4. Percutaneous Endoscopic Gastrostomy (PEG) Tube: Inserted directly into the stomach through the abdominal wall.
  5. Jejunostomy Tube (J-Tube): Inserted directly into the jejunum.

Nursing Management of Enteral Feeding in the ICU

1. Assessment:

  • Nutritional Assessment:
    • Assess the patient’s nutritional needs in collaboration with a dietitian.
    • Calculate caloric requirements based on factors like age, weight, metabolic demands, and disease state.
  • Tube Placement Verification:
    • Confirm proper tube placement before each feeding or medication administration to prevent aspiration.
    • For nasogastric or orogastric tubes, confirm placement using X-ray (gold standard) or pH testing of gastric aspirate (pH ≤ 5 typically confirms gastric placement).
    • For PEG or jejunostomy tubes, verify that the external tube markings are correct and assess for tube displacement.
  • Gastrointestinal Assessment:
    • Monitor for signs of intolerance to feeding, such as abdominal distension, nausea, vomiting, diarrhea, or constipation.
    • Auscultate bowel sounds regularly to assess GI function.

2. Initiating and Administering Enteral Feeding:

  • Starting the Feed:
    • Begin feeding slowly, and gradually increase the rate based on patient tolerance and dietitian recommendations.
    • Monitor for signs of feeding intolerance, including high gastric residual volumes (GRVs), diarrhea, or abdominal discomfort.
  • Feeding Methods:
    • Continuous Feeding: Administered over 24 hours via an enteral feeding pump. Often used in critically ill patients.
    • Intermittent/Bolus Feeding: Administered several times a day, mimicking regular meal times. Suitable for patients with a stable GI function.
  • Gastric Residual Volume (GRV) Monitoring:
    • Check gastric residuals every 4–6 hours (as per hospital policy) during continuous feeding. High residual volumes (>200–250 mL) may indicate feeding intolerance or delayed gastric emptying.
    • Return the aspirated content if within acceptable limits to prevent fluid and electrolyte loss.

3. Monitoring for Complications:

  • Aspiration:
    • Elevate the head of the bed (HOB) to at least 30-45 degrees during feeding and for at least 30-60 minutes after feeding to reduce the risk of aspiration.
    • Regularly assess for signs of aspiration, such as coughing, dyspnea, or oxygen desaturation.
  • Diarrhea:
    • Monitor stool output. Diarrhea may occur due to the feeding formula, medications (e.g., antibiotics), or infection (e.g., Clostridium difficile).
    • Modify the formula or reduce the rate of feeding if diarrhea persists. Collaborate with the dietitian for appropriate changes.
  • Constipation:
    • Monitor for signs of constipation and ensure adequate hydration.
    • Encourage ambulation or repositioning when possible to stimulate bowel motility.
  • Tube Blockage:
    • Flush the feeding tube with 30–50 mL of sterile water before and after feeding or medication administration to prevent clogging.
    • If the tube becomes clogged, attempt to flush it with warm water or a commercial unclogging agent.
  • Infection:
    • Inspect the insertion site (for PEG or jejunostomy tubes) daily for redness, swelling, or discharge.
    • Clean the site using aseptic technique and follow hospital guidelines for dressing changes.

4. Medication Administration:

  • Crushing Medications:
    • Ensure that medications are suitable for administration via the enteral route. Some medications may need to be crushed or dissolved, while others (e.g., enteric-coated or extended-release) should not be crushed.
  • Flushing the Tube:
    • Flush the tube with 30 mL of water before and after administering each medication to prevent clogging and ensure the medication reaches the GI tract.
    • Administer each medication separately to avoid drug interactions and tube occlusion.

5. Preventing and Managing Complications:

  • Fluid and Electrolyte Imbalance:
    • Monitor the patient’s fluid intake and output carefully to prevent dehydration or fluid overload.
    • Evaluate laboratory values for signs of electrolyte imbalances (e.g., hyponatremia, hypokalemia).
    • Adjust feeding formulas or hydration strategies based on lab results and patient condition.
  • Hyperglycemia:
    • Critically ill patients on enteral feeding are at risk for hyperglycemia, especially if the feed contains high levels of carbohydrates.
    • Monitor blood glucose levels regularly and administer insulin as prescribed.
  • Nutritional Deficiency:
    • Monitor for signs of nutrient deficiencies or excesses, particularly in long-term ICU patients on enteral feeding.
    • Adjust the feeding formula if necessary, based on ongoing assessments by the healthcare team.

6. Documentation:

  • Feeding Tolerance:
    • Record the patient’s response to enteral feeding, including any signs of intolerance such as residual volumes, vomiting, or diarrhea.
  • Complications:
    • Document any complications (e.g., aspiration, tube dislodgement) and the interventions performed.
  • Tube Maintenance:
    • Keep a detailed record of tube care, including flushing, repositioning, and any issues related to the tube or feeding system.
  • Nutritional Intake:
    • Track the patient’s daily caloric intake and hydration status, noting any adjustments in feeding rates or formulas.

7. Patient and Family Education:

  • Tube Feeding:
    • Teach the patient and family about the importance of enteral feeding, its goals, and how to identify potential complications.
    • Provide instructions on how to care for the feeding tube, manage tube blockages, and recognize signs of infection (for patients who will continue enteral feeding at home).
  • Nutrition:
    • Educate the patient and family on the role of nutrition in recovery and wound healing, emphasizing the importance of a balanced diet and proper hydration.

Key Nursing Considerations:

  1. Head of Bed Elevation: Always elevate the HOB to reduce the risk of aspiration.
  2. Tube Placement: Verify proper placement of the feeding tube before each feeding or medication administration.
  3. Close Monitoring: Assess for feeding intolerance, GI complications, and nutritional needs continuously.
  4. Collaboration: Work with dietitians, physicians, and pharmacists to adjust feeding plans as necessary.
  5. Prevent Complications: Focus on preventing common complications such as aspiration, infection, and tube blockages.

Conclusion:

Enteral feeding is a crucial part of ICU care for patients who cannot meet their nutritional needs orally. Proper nursing management is key to ensuring the safe and effective delivery of nutrients while preventing complications. By closely monitoring the patient, verifying tube placement, managing feeding tolerance, and collaborating with the healthcare team, nurses play a vital role in maintaining nutritional support and improving patient outcomes.